This article gives you an overview of the SOAP Note (free form) template in AI Scribe.
Table of contents:
What is a SOAP Note?
A SOAP Note is a type of free form clinical note that utilizes the ADA's approved clinical note format. SOAP is commonly taught in dental schools and is often recommended as a default clinical note format in clinical environments.
Click HERE for more information on SOAP on the ADA's website.
The Soap Note captures 1) the full transcript of you speaking and then 2) transforms it into the SOAP format outlined below. There is also a 3) patient summary that is generated when the SOAP note is created.
SOAP stands for:
Subjective (S)
The Subjective section details the patient's "subjective" chief concerns including:
Patient's chief complaint (reason for exam)
Duration of symptoms
Locale of symptoms
Pain level
Medical history
Medications
Allergies
Past medical conditions
Past surgeries
Lifestyle factors
Objective (O)
The Objective section details the clinician's "objective" examinations and observations including:
Vitals (blood pressure, heart rate, respiration, etc.)
Intraoral examinations
Imaging
Periodontal readings
Areas of pain and sensitivity
Oral cancer screenings
Teeth/gum/tissue examinations
Extraoral examinations
Examination of head, neck, lips, face, skin, and thyroid gland
Assessment (A)
The Assessment section details the clinician's findings and diagnosis/diagnoses based on subjective and objective information.
Plan (P)
The Plan section details the clinician's plan for addressing each diagnosis in the form of a treatment plan. The plan section also includes referrals to specialists, lab orders, etc.
Although not part of SOAP, we have also included an Additional Notes section. This section captures any clinical details that do not neatly fit into SOAP section as well as non-clinical/personal details captured during the encounter.
A SOAP Note is ideal for...
Emergency notes
Complex notes
Surgery notes
A default note type for any procedure
Demo video